09 Validation of the francophone version of pGALS with the Delphi approach

Abstract Background The pediatric Gait, Arms, Legs, and Spine (pGALS) is a practical quick musculoskeletal assessment to increase awareness of the joint disease, facilitate early recognition of joint problems, and prompt referral to specialist teams to optimize clinical outcomes. pGALS has been shown to be practical and useful, with excellent acceptability by children and their parents. Its use was limited in French-speaking countries because of the lack of the francophone version. Objectives To describe the steps of the translation of the pGALS francophone version using the Delphi approach. Methods Delphi method is the consensus-building method, providing the consensual opinion of the experts. For each translated item of the pGALS, the experts assessed the relevance using a scale ranging from 1 to 9 (not relevant-completely relevant). Then median was calculated giving for each item the position of the group: disagree (if the median < 3), equivocal (median between 4–6) and agreement (median >7). The degree of the convergence with the group was assessed to clarify this result: the group’s opinion is consensual if 70% of the responses were within the range of the median; otherwise, it’s “not consensual”. For the no consensual and no relevant item, the experts propose a comment to reformulate the sentence. Results Three native speakers were invited to translate the English form of the pGALS into the francophone language. The different propositions were mixed in a consensual way by a children’s musculoskeletal specialist. The version was validated according to the Delphi method. Six experts (pediatricians and rheumatologists) from different French-speaking countries were interviewed during 3 rounds by electronic survey individually and anonymously. After each round: the median, consensus, and comments of every item are collected and a meeting with experts was held to analyze the results. During the first meeting, we were consensual and we had an agreement on 82% of the items (28 items were validated, and 6 items were reformulated). Then the form was reformulated using the results of the preliminary rounds: opinions of the experts and their proposals during the last meeting). We were in agreement and we validated the remaining six-item during the second meeting. In the last round, we obtain a consensual version of pGALS. Conclusion Our approach contributed to the consensual translation of the francophone version of pGALS. This tool is now ready to be used as a basic clinical skill. More research is mandatory to assess its sensibility and specificity in screening musculoskeletal disorders.


Background
Juvenile idiopathic arthritis (JIA) is one of the commonest rheumatic diseases in children. Hip involvement is a common problem in JIA patients and is associated with functional disability and poor outcomes. Intensive therapy is required to avoid joint replacement surgery. Little studied in the literature, the predictors of hip involvement are still unknown.

Objectives
Our study aims to identify the clinical, biological characteristic of patients with hip involvement and determine the associated risk factors. Methods A cross-sectional study including children with JIA according to the International League of Associations for Rheumatology (ILAR). The recorded data included sociodemographic features, disease characteristics (subtype disease, duration, and juvenile arthritis disease activity score (JADAS)) as well as treatment modalities. Regarding coxitis, we collected radiographs, ultrasound (US), and magnetic resonance imaging (MRI) of the hip when performed. Coxitis was defined by clinical (limited range of motion) and/or radiographic findings (destruction, synovitis, bone marrow oedema).

Conclusion
Our study shows that long disease duration exposes to a higher risk of hip involvement in children with JIA. Active disease and biological inflammatory syndrome could be associated risk factors. Studies with larger sample sizes are needed to draw definite causal associations.

Background
Juvenile idiopathic arthritis (JIA) is a group of inflammatory joint diseases that begin before the age of 16. Depending on the clinical form of JIA, medical treatment may involve long-term high-dose corticosteroid therapy, which may lead to aseptic femoral head osteonecrosis of patients. We report three observations of aseptic osteonecrosis of the femoral head in patients followed for JIA. 1st observation: Mr I.A, aged 19 years, presented with ankylosing spondylitis with peripheral involvement, with a juvenile onset, for which he had received a high dose of corticosteroids at an average of 1.5 mg/ kg/day since the age of 15 months on an intermittent basis. Clinically, the patient had a height of 1.65, a right limp when walking and limited movement of the right hip with a Lequesne algofunctional index of 10.5 (significant disability). MRI of the pelvis showed aseptic osteonecrosis of the right femoral head (ONATF), Arlet and Ficat stage 3. Observation 2: Mr A.B, 27-year-old, had systemic JIA since the age of 12. He received corticosteroid therapy at an average dose of 1 mg/kg/ day intermittently. Clinically the patient presents with signs of cortisone impregnation (a cushingoid face, purple stretch marks, thin skin) and bilateral cataract. The patient walks with the help of a crutch. The examination of the hips revealed a limitation of mobility of the left hip with a Lequesne algo-functional index of 18.5. Bone densitometry showed a decrease in bone density. Standard radiographs noted a left ONATF, Arlet and Ficat stage 4 with L4 and L5 vertebral fractures. 3rd Observation: Mr B.M, 26-year-old, followed for systemic JIA since the age of 14. He was treated with high dose corticosteroids at a rate of 1 mg/kg/day. The clinical examination revealed unevenness of the lower limbs, a left limp when walking, limited internal rotation and abduction of the right hip. The patient also had multiple inflammatory acne lesions and a bilateral cataract. Bone densitometry showed a decrease in bone density. Standard radiography showed bilateral ONATF, stage 3 on the right and 4 on the left according to Arlet and Ficat's classification, which required the placement of a double total hip replacement.

Conclusion
Corticosteroid therapy is one of the main risk factors for non-traumatic aseptic osteonecrosis. Our three patients presented with ONAT with major disability following long-term corticosteroid therapy. The efficacy of corticosteroids is well established but they should be used with caution to avoid side effects

Background
The pediatric Gait, Arms, Legs, and Spine (pGALS) is a practical quick musculoskeletal assessment to increase awareness of the joint disease, facilitate early recognition of joint problems, and prompt referral to specialist teams to optimize clinical outcomes. pGALS has been shown to be practical and useful, with excellent acceptability by children and their parents. Its use was limited in French-speaking countries because of the lack of the francophone version.

Objectives
To describe the steps of the translation of the pGALS francophone version using the Delphi approach. Methods Delphi method is the consensus-building method, providing the consensual opinion of the experts. For each translated item of the pGALS, the experts assessed the relevance using a scale ranging from 1 to 9 (not relevant-completely relevant). Then median was calculated giving for each item the position of the group: disagree (if the median < 3), equivocal (median between 4-6) and agreement (median >7). The degree of the convergence with the group was assessed to clarify this result: the group's opinion is consensual if 70% of the responses were within the range of the median; otherwise, it's ''not consensual''. For the no consensual and no relevant item, the experts propose a comment to reformulate the sentence.

Results
Three native speakers were invited to translate the English form of the pGALS into the francophone language. The different propositions were mixed in a consensual way by a children's musculoskeletal specialist. The version was validated according to the Delphi method. Six experts (pediatricians and rheumatologists) from different French-speaking countries were interviewed during 3 rounds by electronic survey individually and anonymously. After each round: the median, consensus, and comments of every item are collected and a meeting with experts was held to analyze the results. During the first meeting, we were consensual and we had an agreement on 82% of the items (28 items were validated, and 6 items were reformulated). Then the form was reformulated using the results of the preliminary rounds: opinions of the experts and their proposals during the last meeting). We were in agreement and we validated the remaining six-item during the second meeting. In the last round, we obtain a consensual version of pGALS.

Conclusion
Our approach contributed to the consensual translation of the francophone version of pGALS. This tool is now ready to be used as a basic clinical skill. More research is mandatory to assess its sensibility and specificity in screening musculoskeletal disorders.

Background
Juvenile idiopathic arthritis (JIA) is the most common inflammatory disease influenced by genetic as well as environmental factors. Prior studies from Israel and USA suggested that JIA had a seasonality of birth, with birth peaking in winter and especially in January.

Objectives
The aim of the study was to evaluate the impact of month of birth and season, and the onset of JIA in Tunisian children.

Methods
We conducted a case-control study including 27 children with JIA compared with a homogeneous control group of 27 children hospitalized in a pediatric orthopedic unit for traumatic reasons and healthy for any chronic inflammatory rheumatism. Statistical differences between groups were also analyzed by non-parametrical tests.

Results
Fifty-four patients (25 females and 29 males) were enrolled. The mean age was 11.04 AE 5.58 years and the mean duration of the diseases was 5.29 AE 3,18 years. The frequency of each JIA subset was at follows: polyarticular rheumatoid factor positive (n ¼ 2), polyarticular rheumatoid factor negative (n ¼ 5), psoriatic arthritis (n ¼ 1), enthesitis-related arthritis (n ¼ 11) and oligoarthritis (n ¼ 8). Although the majority of children with JIA were born in November (22.2%) and December (18.5%), there was no significant difference in month of birth distribution between the cases and the controls. Likewise, there was no significant correlation between season of birth and the onset of the disease (p ¼ 0,6).

Conclusion
This study didn't show any correlation between season and month birth, and the onset of JIA. Our result may be explained by the weather in Tunisia which is relatively warm with little variation in temperature between seasons compared with the country where they found a significant correlation. It also may be due to the limited number of our cases.

Background
Juvenile idiopathic arthritis (JIA) is the most common pediatric inflammatory arthritis. However, this disease is not fully understood by all practitioners.

Objectives
The objective of this survey is to assess the level of knowledge and attitudes of doctors excluding rheumatologists and pediatricians on the management of JIA.

Methods
In this cross-sectional descriptive study, an anonymous questionnaire composed of 20 questions, designed with the Google-Forms software, was sent via social networks to doctors from different specialties (excluding rheumatologists and pediatricians) and to interns and residents of the University Hospitals of Tunis. Results A total of 100 physicians responded to the questionnaire (61 women and 39 men). The mean age was 31.01 AE 5.64  years. Fiftyseven percent of the participants were in training, 27% worked in public hospitals and 16% in private clinics. Most participants were general practitioners (32%), followed by ophthalmologists (9%), gynecologists (7%), and internists (5%). the mean length of service was 4.99 AE 4.5 [0-22] years. Thirty-six participants affirmed they have been confronted with patients with JIA. Twenty percent of participants believed they have knowledge about JIA. Among them, 25% believed they have sufficient knowledge, the others had superficial knowledge. Thirty-four percent of participants knew the definition of the disease according to the age, 17% knew its frequency and 18% had an idea about its various sub forms. The most frequent sub form was known only by 32 participants. Regarding the complications of JIA, only 25% of the participants thought of the macrophage activation syndrome in case of deterioration of the general state, fever, and pancytopenia. In addition, 44% of participants knew that JIA can be complicated by ocular involvement. Concerning the presence of rheumatoid factors and anti-nuclear antibodies during JIA, 64% and 60% respectively answered that their presence was not necessary. Concerning the care of JIA, 64% of participants referred these patients to rheumatologists, 31% to a pediatrician, and 5% took care of them themselves. The interest of methotrexate and biological treatments were known by 48% of the participants. However, 37% of participants had no idea of the therapeutic management of JIA. Concerning the prognosis, only 25% of the participants know the sub forms of bad prognosis. However, 48% had no idea about the prognosis of the disease.

Conclusion
The level of knowledge of doctors on JIA is low to average. Training for physicians on this potentially serious disease is needed.

Objectives
To assess the frequency and associated factors with hip involvement in (JIA).

Methods
We conducted a retrospective study including adults with longstanding JIA according to the International League of Associations for Rheumatology (ILAR) criteria over a period of 28 years . Demographic, clinical, biological, and radiographic data were collected. These parameters were compared according to the presence or absence of hip involvement. Results A total of 29 Patients were enrolled (12 men and 17 women), the mean age was 35.69 AE 11.72    -218] mg/l, a biological inflammatory syndrome was present in 19 cases. Rheumatoid factor, ACPA and anti-nuclear antibodies were observed in 12, 7 and 5 cases respectively. At least one extra-articular manifestation was noted in 16 cases. Hip involvement was noted in 14 patients (48.3%). It was bilateral in 64.3% of cases (n ¼ 9). Twenty-three hips were affected in total (56.9%). Hip involvement was diagnosed 14.5 AE 9.37 [1-28] years after